Employee Claim - Workers' Compensation Board - NY.gov 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the Claimant's Name and WCB Case Number in the designated fields. Ensure accuracy as these details are crucial for processing your claim.
3. Fill in the Claimant's Social Security Number, Date of Accident, Employer's Name, and WC Carrier Case Number. Each field must be completed to avoid delays.
4. Specify the Reimbursement Amount Requested and provide the Date of Full or Partial Match if applicable. Indicate whether an ANCR was established.
5. Complete the sections regarding Health Insurer’s information, including their Federal Tax ID No., Email Contact, and Telephone Number.
6. If there are objections from the WC Insurance Carrier, fill out Part II with detailed explanations for each objection listed.
7. Finally, review all entries for accuracy before signing and dating the form. Use our platform’s features to save your progress and ensure a smooth submission process.

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